遅発性心室中隔穿孔に対する経右房アプローチ修復術

Right Atrial Approach for the Surgical Repair of Delayed Ventricular Septal Rupture

心室中隔穿孔（VSP）は急性心筋梗塞（AMI）の重篤な機械的合併症であり，その発生率は低いが現在でも死亡率は高い．われわれは，右冠状動脈（RCA）を責任病変とする亜急性期心筋梗塞（RMI）に対する経皮的冠状動脈形成術（PCI）後，遅発性に生じた高位下壁のVSPに対し，待機的に経右房アプローチによる修復術を行い，良好な結果を得たので文献的考察を加えて報告する．

Ventricular septal rupture （VSR） after acute myocardial infarction （AMI） is a rare and serious complication that is associated with extremely high mortality. Delayed VSR is particularly uncommon and is difficult to diagnose and treat. A 68-year-old man presented with dyspnea on effort. Coronary angiography revealed subtotal occlusion of the right coronary artery （RCA） with collateral circulation to the chronically and totally occluded left anterior descending artery （LAD）. Elective stenting of the RCA was successfully performed for a recent MI of the RCA, while percutaneous coronary intervention （PCI） in the LAD ended in failure. At 21 days after the 1st PCI, the patient developed acute heart failure with new pansystolic murmur. Cardiac catheterization showed a left to right ventricular shunting without new coronary artery lesions. Fortunately, the hemodynamic status was stable, and we could perform elective surgical repair by right atrial approach. Simultaneously, a left internal thoracic artery bypass to the LAD was performed. The postoperative course was uneventful. The patient is currently doing well at 5 years after the operation.